Do any hospitals out there have policies that indicate a new PICC after multiple doses of cathflo? By multiple doses I mean an effective dose one day and then another dose a few days later for a reclotted PICC and on and on..... We are discussing PICCs, biofilm, CLABs and and are considering implementing a maximum Cathfo dose policy-would like to see what others in the World of PICC are doing.
Also who is responsible for declotting PICCs in your hospital-IV Team or unit nurses?
All answers are grealtly appreciated.
Ann Y Rn
AGH
I have never seen such a policy. What is probably happening is you are reaching the amount of fibrin only at the catheter tip. Over the ensuing days, the fibrin regrows and prohibits blood return again. You will need to reach the entire fibrin sheath around the outside catheter wall. This is done by a low dose infusio of tPA - usually 10 mg in 50 mL infused over 3 hours through each lumen. This is one protocol I have seen but I am sure there are others. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I had only heard about infusing 2mg over 2 hours. I hadnt heard about 10mg. I would like to know what dosage other hospitals are using. Also, any articles regarding alteplase infusion?
Thanks,
Dawn
I often find that a PICC which becomes occluded over and over again is in fact malpositioned. I now seek out those PICCs which are being declotted multiple times and immediately look at the most recent CXR; seriously, more often than not, I will find the PICC's tip to terminate in either the proximal SVC, the brachiocephalic/SVC junction, the junction of the brachiocephalic veins or even in the L or R brachiocephalic vein. The worst part is that the PICC will be reported by radiology as being "in place" or at best, "in the SVC" so no one suspects a malpositioned PICC being the cause of the recurrent occlusions.
Liz Holowasko RN, BSN, CRNI
St. John Providence Health System
Assistant Clinical Manager
You have just explained why nurses should be assessing tip location on chest xrays. And the next step is to assess tip location by ECG and not rely on chest xray unless there is no p wave change. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn, Can the tpA procedure you are refering to be done in the home setting?
Valorie Dunn,BSN, RN, CRNI, PLNC
I know that the instillation procedure of 2 mg in 2 ml is done in the home, but I don't think the low dose infusion is done in the home. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
All CVAD are prone to occlusions. In the Cathflo (t-PA) studies they used 2 doses (2mg/2ml) in 24 hours. That was all that was studied because of the high success rates. Remember this is the only drug on the market that has NO warnings! It has limited systemic exposure; you are treating the inside of the catheter. We have about 2mg naturally in the body; the tiny bit that does get to the blood stream has a half-life of 5 minutes!
I would agree first a CXR needs to be repeated to make sure the tip is in optimal position. Less than optimal will lead to higher occlusion rates. If in fact it is in the lower one third of the SVC, then I would look at how much you are flushing the device with after blood draws, it may not be an adequate amount. What is your flushing and clamping sequence? The average nurse does not understand the importance of this, which may be leading to occlusions.
You have to weigh the benefits verse the risks of replacement. How much longer does the patient need the device if it is sub optimally placed? What if you can’t get a new one in?
All these points demonstrate the need for full Vascular Access Teams 24/7. The average nurse doesn’t understand all this. When we all are trying to achieve zero BSI there is no better way to do so than with a Vascular Access Team, that provides all this care 24/7.
Cathflo (t-PA) is used in nursing homes and by Home Health. All the literature and the FDA state to use 2mg to treat occlusions. Some hospitals are still sub-therapeutically treating these devices but complain about using too much t-PA. Why do we blame products instead of looking at practices?
Cathflo (t-PA) is not the bad guy here, cathflo is the answer to occlusions, what we need to do is look at all the people that touch these devices and think about their practice and knowledge regarding CVADs !